Sharing CAPA from a recent SABRE incident

As you will well know, when reviewing SABRE reports I often contact reporters to establish further information to help establish the root causes and CAPA that addresses these. I will often do this because sometimes the suggested CAPA doesn't address the human factors involved. Sometimes a member of staff will skip a step from a process and this results in the error. More often than not that person will be "re-trained" despite there being no evidence that a failure to understand or deliver adequate training was the root cause. This overlooks the real root causes and by-passes a chance to identify more appropriate improvements to the QMS, or an opportunity for the member of staff to properly reflect on changes to their actions. Often staff might feel that they are somehow to blame, even if that wasn't the intention of the CAPA.

A recent report from where a BMS omitted a step from process and issued blood without undertaking an antibody screen or checking maternal antibody status provided a transcript from an email exchange between the lab manager and BMS involved. With permission, I have copied the transcript below because I felt this was an excellent way to approach the investigation with the BMS involved.

Interview between BMS and TLM
I have been reading through your reflective learning from the incident where the antibody status was not checked before issuing blood.

I wanted to speak to you but you are on nights so I have put a couple of questions for you.

First off you have said about applying what you have learnt from the incident is that you will get staff to check your work. I donít think this is necessary. You know what the procedure is, something happened that stopped you doing that check. This is a check you have done a thousand times before so I feel there is something else to be learnt and I think the following questions may help.

You said you just forgot to check.

What time was it? 01:32

How much pressure were you put under to supply the blood quickly?
Twin to twin transfusions can be life threatening.
Had you had sufficient breaks?
Were you hydrated?
Were you by yourself?
Was someone in there with you? Did they distract you?
How tired did you feel?
Was there other things going on that could have distracted you.
Did you feel that you had to do other issues or jobs urgently that may have been on your mind distracting you?
Do you feel you have been trained sufficiently?
Has it been a long time since you have issued neonates with blood?

It might be that after you have thought about all of the above you can still not think of a reason that may have contributed to you forgetting to check. Donít forget we are built for day time activity working through the night is different and the risk of error is increased for everyone.

If you can decide what contributes to the error you can address it in some way.
Make sure you have your break, if you are busy how much of that work is life dependent that can't wait 20 mins before starting.
Donít think to yourself, ď I will just do that one little thing and go for a breakĒ as something else will pop in and you do the same. Before you know it another hour has gone by.

You are a good BMS you have done blood issues to neonates multiple times, I personally do not feel you need supervising or checking of your work unless you have recognised a particular risk such as being over tired on an occasion.

BMS- I must say I was very disappointed with myself, I couldn't believe I made such a silly mistake. Quite a blow for a perfectionist like me

1.
BMS- It was busy night. I received request for blood long before any samples arrived. When they did arrive, one of them was not quite correctly labelled-concessionary release form.

2.
BMS- I probably didn't have a break until 3:30 am and that is something I need to work on.
TLM -That is four hours with no break at the point of the incident and 6 hours till you did get a break. This to me is the root cause. No one can keep going with full concentration for that long without a break especially at night.
BMS- I always have that feeling that I should get things done before anything happens (trauma, massive haemorrhage) so I try to finish everything before I go on my first ( and probably the only) break. And I don't like to leave unfinished work for early people.
TLM- This is common to so many, and others are the complete opposite. We only have true emergency task rarely. The way I would think about work when I used to do nights was how long would this sample take in the day time? It probably would be with lots of other samples and would be booked in by reception and go through the analysers ect ect. The service you provide at night is probably better than the urgent pathway in the day.
The take home point is that if you left a sample for 30 minutes to an hour do you think it would affect the patient?

If a trauma comes in you would leave the other work till it had calmed down this could be more than an hour. We have never had a complaint to say fbc or CS results were not available. Donít try and get everything done.
You need to look after yourself first. This may seem counter intuitive but there are only a few truly emergency situations that would stop you taking a break.
In an air craft when the oxygen masks come down they say put yours on first then help the child next to you. This is because you cannot help someone else if you are compromised.

3.
BMS - As for distraction. I don't know if it is only my feeling but I noticed that doctors seems to phone the lab instead of bleeping us and they are quite stubborn. They stay on the phone for so long that at the end you just give up and answer it.
TLM - This is because some staff do answer the phone at night so they expect it every time. This has made a rod for all haematology staff. I will bring this up with xxx and xxx to see if we can get some communication out to the Trust to explain that Transfusion is staffed by one BMS at night and one in Haematology. I think the clinical side think we are fully staffed at these times.

4.
BMS -It's been a long time since I have issued blood for babies but I am confident that I have been trained sufficiently.
TLM - Good

BMS -Sometimes when someone is tired the brain switches to an automated mode when you do things and you don't remember them or you think you've done something but you didn't ( hope it makes sense) - lapses of concentration.
TLM -Very true. Thatís why your breaks are so important.

BMS - To sum up. I made that mistake and I can't go blaming everything and everyone for it. We all do nights, they are busy and we are tired. We all make mistakes and luckily this time nothing happened ( no harm done). I just need to remember to stay focused.
TLM - Its not about blame. This was a simple excursive to determine how it came about. You have come up with the corrective action about not trying to do everything before going for a break. This is near impossible as more work will always flow into the lab. Take a look at what is there decide how long they can wait I doubt hardly any samples cannot wait 30 minutes. ED have a turnaround time of an hour for FBC and CS. There are two on a night and also now started is a reception staff too.

BMS - Hopefully that answers some of your questions.
TLM - It does, Thank you. Have a think about what we have discussed via email and let me know if you feel you can make a change to ensure you get your breaks in. We can have a quick catch up if that would help especially if you think it will be difficult to still get breaks in.

Thanks so much for sharing this Chris - although I don't work directly in this field it is a fantastic example of how to truly engage people in root cause analysis of an incident. Often people are not able to see past "human error". I am going to share this with some of my colleagues to help us facilitate RCA in future.